Birth After Previous Caesarean Birth
RCOG
ANC
NICE antenatal care guideline
counselling for mode of delivery
contraindications of VBAC.
ANC
Measurement of lower uterine
segment (LUS) thickness antenatally in
women with a previous caesarean
delivery could be used to predict the
occurrence of a uterine defect (scar
dehiscence or scar rupture) in women
undergoing VBAC.
Suitability
Planned VBAC is appropriate for and may
be offered to the majority of women with
a singleton pregnancy of cephalic
presentation at 37+0 weeks or beyond who
have had a single previous lower segment
caesarean delivery, with or without a
history of previous vaginal birth.
Contraindication
women with previous uterine rupture or
classical caesarean scar and in women
who have other absolute
contraindications to vaginal birth that
apply irrespective of the presence or
absence of a scar (e.g. major placenta
praevia).
ANC
Overall aims:
The antenatal counselling of women
✓
Evidence
level 4 with a previous caesarean birth should
be documented in the notes.
A final decision for mode of birth
should be agreed upon by the woman
and member(s) of the maternity team
✓
before the expected/planned date of
delivery.
Evidence
level 1+ When a date for ERCS is being
arranged, a plan for the event of labour
starting before the scheduled date
should be documented in the notes.
✓
The routine use of VBAC checklists
during antenatal counselling should be
considered, as they would ensure
informed consent and shared decision
making in women undergoing VBAC.
B
A patient information leaflet should be
provided with the consultation.
✓
Women who have had two or more prior
lower segment caesarean deliveries may
be offered VBAC after counselling should
B include the risk of uterine rupture and
maternal morbidity, and the individual C
likelihood of successful VBAC
Contraindication
women with previous classical
Evidence
D caesearean delivery due to the high risk
of uterine rupture
level 3
 Factors that potentially increase the risk of uterine rupture:
 short inter-delivery interval (less than 12 months since last
delivery),
 post-date pregnancy,
 maternal age of 40 years or more, Evidence
 obesity, level 3
 lower prelabour Bishop score,
 macrosomia
 decreased ultrasonographic lower segment myometrial
thickness.

Intrapartum management of planned VBAC

Women should be advised that planned VBAC should be conducted in a suitably
staffed and equipped delivery suite with continuous intrapartum care and ✓
monitoring with resources available for immediate caesarean delivery and
advanced neonatal resuscitation.

Women with an unplanned labour and a history of previous caesarean delivery

should have a discussion with an experienced obstetrician to determine feasibility
✓
of VBAC.

Epidural analgesia is not contraindicated in a planned VBAC, although an

increasing requirement for pain relief in labour should raise awareness of the D
possibility of an impending uterine rupture.

D
Women should be advised to have continuous electronic fetal monitoring for
the duration of planned VBAC, commencing at the onset of regular uterine
contractions.

All women in established VBAC
labour should receive:
l supportive one-to-one care
l intravenous access with full blood
count and blood group and save
l continuous electronic fetal
monitoring
l regular monitoring of maternal
symptoms and signs
l regular (no less than 4-hourly)
assessment of their cervicometric
progress in labour.
The clinical features associated with uterine scar
rupture include:
 l abnormal CTG
 l severe abdominal pain, especially if persisting
between contractions
 l acute onset scar tenderness
 l abnormal vaginal bleeding
 l haematuria
 l cessation of previously efficient uterine activity
 l maternal tachycardia, hypotension, fainting or
shock
 l loss of station of the presenting part
 l change in abdominal contour and inability to pick
up fetal heart rate at the old transducer site.